Manage the Frequent Visitor

Looking for a better way to manage your time with time-consuming patients -- like the elderly or those with chronic conditions? One easy and inexpensive solution is to start by pausing for a breath. Susan Keane Baker, a former hospital executive and author of "Managing Patient Expectations," recalls a story about a physician who had been giving pre-procedure instructions to a patient at his office.

"The physician was firing off the information very quickly, but the patient didn't interrupt. When the physician finished talking, the patient asked, 'Could you repeat that?' 'Repeat the whole thing?' asked the physician. She said, 'Yes. You spoke so quickly that I kept trying to retain what you just said and didn't get any of it.'" The result? A confused patient, a frustrated physician, and squandered time.

Handling patients who require excessive time can be irritating for physicians and damaging to the practice's schedule. But it's a situation many physicians have to endure. According to a survey of 1,236 physicians by The Partnership for Solutions, an organization designed to raise awareness and address concerns of the chronically ill, led by The Johns Hopkins University and The Robert Wood Johnson Foundation, 80 percent of the respondents reported that they spend more than half of their time treating people with chronic conditions; and 50 percent to 60 percent said that they were not adequately prepared in medical school or during residency to provide care for these patients, who, by 2000, accounted for nearly half of the U.S. population -- 125 million Americans.

As a reminder about how it feels to be elderly or chronically ill, Keane Baker suggests that physicians try wearing earmuffs around the house. "If you begin to agree to statements without understanding them, or start to give fake answers because you are tired of saying, 'What did you say?' you may recognize a need to speak more slowly when you're with patients, and repeat, or even write down, your question when you receive a nonsensical reply from a patient," she says. Making sure you understand each other the first time around can help to reduce unnecessary repeat visits or follow-up calls.

Keep it moving

To keep an exam moving at a pace that works for both the physician and patient, Gerard Anderson, PhD, proposes asking several standard questions of patients you see frequently:

• Since the last time I saw you, have you visited a hospital, emergency room, clinic, or another doctor's office?
• Were you prescribed any new medications or discontinued on any medications?
• Has anything else changed about your condition since the last time I saw you?
• What specific problems do we want to address today?

These items can help you get to the root of recurring or unresolved problems that bring patients back to their physician's office repeatedly.

"Most of the time these patients have multiple illnesses. You treat one part of the illness, but other illnesses tend to be very much undertreated," says Anderson, a professor of medicine at Johns Hopkins University School of Medicine and national program director for Partnership for Solutions. "You've got to be aware of the other problems patients have and make sure they get appropriate care."

Following the initial questions, concentrate on more specifics, such as care plans or instructions, communicated as short, understandable pieces of information. Remember to be seated when talking to the patient says Paula Hall, a family practice physician in Indianapolis, Ind. "Sit down with your patient. If you stand up while talking to the patient it appears as if you're rushed. Then, the patient gets anxious and doesn't want to let go of you," says Hall.

Guiding patients to practice certain behaviors for particular conditions -- like diabetes, for instance -- will minimize your time with them in the future, says Hall. "Have patients bring in a list of their blood sugar levels and all of their medications. Also, these patients should have their shoes and socks off when you walk into the exam room," she says. "This reinforces to them the need to look at their feet everyday. Neglecting to check for and prevent complications like foot problems will likely lead to more frequent visits and complex care later on. "If you don't examine their feet, they're not going to think it's important for them to do it," Hall emphasizes.

Your patient's role

Patients need to take part in making the visit a productive and efficient one as well, says Hall. "Tell patients to bring a list of questions with them. Then the doctor, patient, or caregiver can even write the answers during the visit. When people go to the doctor's office they only hear about half of what you say because they are nervous."

There are also ways to save time during the exam by assigning the patient some pre-appointment tasks. Plus, requesting that patients take responsibility for their healthcare can result in their having decreased feelings of helplessness, says Keane Baker. She suggests physicians consider the following prior to an office visit.

• Send medical history forms to the patient to be completed in advance.
• Order routine blood tests and screening exams so that the results are on hand when the patient sees you.
• Provide a list of community health services available to the patient, such as Ask-A-Nurse.
• Mail articles on health issues, or request that the patient attend an educational program or support group prior to the visit.

If your preparation efforts still aren't solving the problem of bogged-down appointments, some visits may have to be rescheduled.

"If there's a patient with multiple serious conditions, you may need to tell them, 'We put you in a time slot for treating your sinus infection and you obviously need more time. Would it be OK with you to come back this afternoon or tomorrow?'" suggests Hall. "It's better to do that than to get an hour behind. You can also say, 'What are the two most important things you need me to address right now?'" And if there are patients who generally take more time than others, put them at the end of the day, she adds.

"But remember -- you have to be fair to the patient. Often they are taking off work to come see you. Plus, they're paying for it," says Hall.

Share the care

Some physicians find themselves becoming a sounding board for chronically ill, older, or other time-consuming patients. A patient's loss of health is magnified when it is accompanied by the loss of social interaction. The office visit with the physician then becomes a rare opportunity for that patient to engage in social conversation, says Keane Baker. But most physicians simply don't have the time.

Group visits are a venue for patients with a shared condition to interact with each other and discuss health concerns in detail -- and they ultimately save the physician time.

Group visits can allow you to see an average of 10 to 16 patients in an hour versus spending up to 30 minutes per person. This model can also help with patient compliance, involve family members if appropriate, and can assist physicians with diagnosis and treatment.

"The group visit also provides an opportunity for patients to get to know other members of your staff," says Keane Baker. This becomes important when they call in for advice. A patient who knows the nurse practitioner is far more likely to take his or her direction, enabling the practice to handle patient concerns by phone rather than with another office visit.

Patient progress

Helping to improve a patient's quality of life will also decrease the amount of time he or she will need to spend with the physician.

Some patients don't want to believe the magnitude of their condition, or they associate "feeling better" only with being cured of a disease. When this is the case, the physician has the challenge of convincing the patient that feeling better really means having the skills and tools in place to enjoy meaningful activities, says Keane Baker.

"Finding out who the person was before the adult onset of chronic illness will provide the physician with some clues as to the patient's goals and motivations," she adds.

Respecting the patient's preferences and encouraging him or her to pursue new interests or activities can result in more independence. With these efforts, physicians can save valuable time that can be used to see additional patients.

Karen Gatzke can be reached via editor@physicianspractice.com.

This article originally appeared in the Spring 2002 issue of Physicians Practice.